Pharmacist Suspended for Unsafe Remote Prescribing of High-Risk Medicines

Date of Decision: August 28, 2025

Registrant's Role: Pharmacist

Allegations:

Prescribed over 3,000 high-risk prescriptions through online pharmacies without proper clinical assessments.
Relied solely on online questionnaires without face-to-face or virtual consultations.
Failed to access GP or specialist records, compromising patient safety.
Issued prescriptions for controlled drugs (e.g., opioids, z-drugs) inappropriately and without due consideration of dependence or misuse.
Approved repeat prescriptions for patients with signs of drug-seeking behaviour.
Failed to refer patients to their GPs or implement safety netting.
Demonstrated a transactional approach to prescribing rather than one based on clinical need or UK prescribing guidance.

Outcome: Four-month suspension with a review; immediate interim suspension ordered.

GPhC Standards Breached:

Standard 1 – Person-centred care: Failed to put the care of individuals first by not conducting appropriate assessments.
Standard 2 – Partnership working: Did not collaborate with GPs or other professionals.
Standard 4 – Professional judgement: Exercised poor judgment in issuing high-risk medications based solely on questionnaires.
Standard 6 – Communication: Did not engage in any form of meaningful patient communication or follow-up.
Standard 7 – Confidentiality and privacy: Failed to properly safeguard patient data and history by neglecting to access GP records.
Standard 8 – Speaking up about concerns: Did not challenge unsafe prescribing models or raise concerns.
Standard 9 – Leadership: Did not act as a responsible professional despite having the autonomy to make prescribing decisions.

Case Summary

Allegations

This case concerned serious concerns about a pharmacist’s practice in online prescribing roles at two remote pharmacies: Instant E-Care Ltd and UK Meds Online Ltd. Between May 2019 and January 2020, the registrant issued a combined total of over 4,300 prescriptions, including high-risk medicines such as opioids (codeine, dihydrocodeine), z-drugs (zopiclone, zolpidem), modafinil, antidepressants (sertraline, citalopram), and other medications requiring ongoing monitoring.

Allegations centred on the registrant’s over-reliance on online questionnaires, lack of any virtual or in-person consultations, failure to verify medical histories, and failure to contact patients’ GPs. The prescribing was done in a transactional manner, often in the absence of any safety netting or professional judgment grounded in established clinical guidance.

For example, Patient A received dihydrocodeine despite inconsistencies in their questionnaire and a lack of clarity about their GP status. Patient B, known to have a history of opioid dependence, was prescribed 200 codeine tablets without adequate assessment or safeguards. Schedule A and B of the determination detailed dozens of such instances, many of which involved repeated orders from patients.

Findings

The registrant admitted all allegations. The GPhC panel found that he had “routinely failed to prescribe in accordance with accepted standards.” Prescribing decisions were made without due regard to guidance from the General Medical Council (GMC), Royal Pharmaceutical Society (RPS), or the GPhC itself. High-risk drugs were prescribed in a context that offered no viable clinical oversight.

A key issue was the manipulation of questionnaires. The system would flag responses that would prevent supply and alert patients to change them. The registrant did not account for this vulnerability in their decision-making, even though the system flaw was well known.

The GPhC noted that the registrant continued prescribing at UK Meds even after significant regulatory scrutiny and a statutory Improvement Notice issued in September 2019. This suggested a persistent pattern of unsafe practice.

GPhC Determination on Impairment

The Committee concluded that the registrant’s fitness to practise was currently impaired on the basis of misconduct. They were particularly concerned that the registrant:

“…repeatedly placed patients at unwarranted risk of harm through the irresponsible prescribing of high-risk medicines without sufficient clinical scrutiny.”

The Committee did acknowledge that the registrant had engaged in some reflective work and had continued to work in a face-to-face NHS setting without incident since leaving these roles. However, it held that the behaviour was not an isolated lapse and had occurred over a sustained period with multiple patients.

Sanction

The panel imposed a four-month suspension with a review before re-entry to the register. This was to allow time for further remediation and reflection. The panel opted not to impose removal from the register due to mitigating factors, such as the registrant’s admissions and the absence of direct patient harm that could be evidenced.

An interim suspension was also issued to protect the public during the appeal window.

Key Learning Points for Pharmacy Professionals

Online prescribing must meet the same clinical standards as face-to-face care: Reliance on digital questionnaires without corroborative clinical information is unacceptable, especially for high-risk medicines.
Clinical independence must be exercised responsibly: Pharmacists working in remote or commercial models must not compromise clinical judgment under pressure or due to system design flaws.
Failure to access or verify GP records is a critical breach: Prescribers must make efforts to obtain complete medical histories, especially for medicines prone to abuse or dependence.
Unsafe systems must be challenged: Pharmacy professionals have a duty to raise concerns when working in environments that compromise patient safety.
Controlled drugs and z-drugs demand stringent oversight: Medicines like codeine, dihydrocodeine, zolpidem, and zopiclone should not be issued based solely on patient self-assessment due to their misuse potential.
Transactional prescribing undermines professional trust: The Committee emphasised that treating patients as “tick-boxes” rather than individuals with complex needs erodes professional standards and public confidence.
Compliance with GPhC standards is non-negotiable: Ignorance or disregard of professional standards, even in commercial settings, will not be tolerated.

This case serves as a stark warning to pharmacists involved in online prescribing services, particularly where commercial interests may conflict with patient safety. Pharmacists must always act as the final clinical safeguard—not as passive facilitators of medicine supply.

Original Case Document

The full determination transcript is available to logged in users.